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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Child maltreatment

Actions to take:

Interview the child separately from the parents

Ask a parent, away from the child

Parameters to monitor:

Signs of fear or apprehension from the child when either parent is present

Negative comments about child from either parent.

Rationale:

Potential Condition: Child Maltreatment

The client’s history of multiple injuries (bloody nose, sutures from hitting cabinet, and spiral fracture) in the context of the parent’s alcohol intoxication, slurring, and aggressive behavior raises concern for possible child maltreatment. The child’s statement about being "clumsy" and the observed scars also support the need for further investigation into possible abuse.

Actions to Take

Interview the child separately from the parents: To ensure the child can speak freely and report any concerns without the influence or presence of the parents, especially when maltreatment is suspected.

Ask a parent, away from the child: The parent should be interviewed privately to assess their behavior and any possible stressors or issues that could indicate abuse or neglect, especially considering their appearance and actions when visiting the child.

Parameters to Monitor

Signs of fear or apprehension from the child when either parent is present: This could indicate emotional distress or fear related to the parent’s behavior. It is important to observe how the child reacts to the presence of each parent during assessments.

Negative comments about the child from either parent: Verbal abuse or negative comments can be a red flag for emotional abuse or neglect. Careful attention should be paid to any signs of verbal maltreatment.

Potential Diagnoses: Incorrect Choices

Muscular Dystrophy: While this could explain a pattern of injury due to muscle weakness, it does not align with the history of multiple injuries caused by trauma or the current family dynamics.

Constipation: No evidence or symptoms supporting constipation were observed in the current assessment.

Strabismus: No direct evidence to suggest strabismus in the child’s history or exam.

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Correct Answer is A

Explanation

A. Decreased attention span is a common manifestation of increased intracranial pressure, as pressure on the brain can affect cognitive function.

B. Hyperactivity is not typically associated with increased intracranial pressure. It would be more common for the child to exhibit lethargy or irritability.

C. Tachycardia is not a primary symptom of increased intracranial pressure. Typically, bradycardia (slow heart rate) is seen in cases of severe intracranial pressure.

D. Hypotension is not usually associated with increased intracranial pressure. In fact, increased intracranial pressure often leads to elevated blood pressure and a widening pulse pressure.

A. 2 mL/kg/hr B. 7.5 mL/kg/hr C. 0.5 mL/kg/hr D. 15 mL/kg/hr

Correct Answer is A

Explanation

A. A normal urinary output in infants is approximately 1-2 mL/kg/hr. An output of 2 mL/kg/hr would indicate that the fluid imbalance is being corrected.

B. An output of 7.5 mL/kg/hr is excessive and may indicate overhydration or other complications.

C. An output of 0.5 mL/kg/hr is too low and suggests that the fluid imbalance is not yet corrected.

D. An output of 15 mL/kg/hr is too high and could indicate a possible issue such as overhydration.

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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

Correct Answer is A

Explanation

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance?

Correct Answer is A

Explanation

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate?

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A school nurse is taking care of an adolescent who presents with multiple burns in various stages of healing. which of the following behaviors should the nurse identify as a suggestive of possible physical abuse?